Gamma-hydroxybutyrate, commonly known as GHB, is a substance that acts as a central nervous system depressant. It naturally occurs in small amounts within the human brain, where it functions as a neurotransmitter. However, GHB also exists in two distinct forms: a precisely regulated prescription medication and an unregulated, illicit street drug. Understanding the differences between these forms is important, especially concerning their effects on sleep and associated dangers.
The Medical Application for Sleep Disorders
The approved medical application of GHB is specifically formulated as sodium oxybate, available under brand names like Xyrem and Xywav. This medication is not a general sleep aid for common insomnia; rather, it is prescribed for individuals diagnosed with narcolepsy. Narcolepsy is a chronic neurological condition characterized by overwhelming daytime drowsiness and sudden sleep attacks, alongside fragmented nighttime sleep.
Sodium oxybate effectively addresses two primary symptoms of narcolepsy: excessive daytime sleepiness (EDS) and cataplexy. Cataplexy involves sudden episodes of muscle weakness or paralysis, often triggered by strong emotions. By improving nighttime sleep quality, the medication helps reduce both persistent daytime sleepiness and the frequency of cataplexy attacks. In the United States, medically prescribed sodium oxybate is categorized as a Schedule III controlled substance, reflecting its accepted medical use but also its potential for abuse.
Mechanism of Action on Sleep Architecture
Sodium oxybate exerts its effects by interacting with specific receptors in the brain, primarily the gamma-aminobutyric acid B (GABA-B) receptors. GABA is the brain’s main inhibitory neurotransmitter, and by activating its receptors, sodium oxybate helps to calm neuronal activity. This interaction leads to a significant consolidation of fragmented nighttime sleep, reducing awakenings throughout the night. A notable effect of sodium oxybate is its ability to increase the duration and power of slow-wave sleep, often referred to as deep sleep. Enhancing this restorative phase of sleep contributes to reduced daytime sleepiness and improved sleep continuity.
Risks and Contraindications of Medically Prescribed GHB
While medically prescribed sodium oxybate can be beneficial, it carries risks and contraindications that necessitate careful medical supervision. Common side effects include nausea, dizziness, headache, bedwetting, vomiting, and tremors.
More serious risks include profound sedation and respiratory depression, which can be life-threatening. For this reason, the medication carries a Black Box Warning from the FDA, the strongest warning issued. It is dangerous to combine sodium oxybate with alcohol or other central nervous system depressants, such as opioid pain medicines, sedatives, or muscle relaxants, as this can severely increase the risk of respiratory arrest, low blood pressure, and unconsciousness.
Due to these significant risks and its potential for abuse, sodium oxybate is available only through a tightly controlled Risk Evaluation and Mitigation Strategy (REMS) program. This program ensures the medication is dispensed only through a central or certified pharmacy to patients who have been fully counseled on its proper use and potential dangers. Prescribers must also enroll in and comply with all REMS program requirements to help mitigate misuse and abuse.
Illicit GHB Versus Prescription Formulations
Illicit GHB, often found on the street, differs significantly from its prescription counterpart, sodium oxybate, and poses severe dangers. Unlike the regulated medical formulation, illicit GHB is classified as a Schedule I controlled substance in the U.S., indicating it has no approved medical use and a high potential for abuse. Using street GHB for any purpose, including self-medicating for sleep, is illegal and extremely hazardous.
The primary danger of illicit GHB stems from its unknown purity and dosage, as it is often produced in unregulated labs and can be contaminated with industrial solvents or other harmful substances. Consuming street GHB can lead to unpredictable and severe effects, including rapid unconsciousness, profound respiratory depression, seizures, coma, and even death, especially when combined with alcohol. This unregulated substance is also widely known as a “date rape” drug because it is typically a colorless and odorless liquid that can be slipped into drinks undetected, leading to incapacitation, memory loss, and vulnerability for victims.